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Delivery Note:

Mom ID: Age, GTPAL, Weeks Gestation at delivery, GBS Status, Blood group, other pertaining labwork (TSH, VZV, Rubella, Chlamydia/Gonorrhea/Herpes,  Diabetes)

Time of membrane rupture:
Time of labour onset:
Time of delivery baby delivery:

Type of delivery: Spontaneous Vaginal Delivery, or Assisted vaginal delivery (vacuum or forceps), or C-Section.

Baby: Sex, perinatal complications (None or Nuchal chord, meconium, shoulder dystocia, spontaneous breathing or required BiPAP?, Hypoglycemia, Hyperbilirubinemia), APGARS at 1, 5 and 10 mins, weight, time at cord clamping (e.g. 1 min)

Maternal Complications: None or Episiotomy, laceration repair (what degree?), post-partum hemorrhage or infection.


Placenta: Time of placenta delivery, spontaneous or required gentle cord tug or other interventions, placental anatomy (Intact?, multiglobular), Number of cord vessels


Most responsible physician: Name of person delivering baby (Fam dr, OB, midwife)

Type of anaesthesia used and Anesthetist name

Where is the baby and mom admitted to?